Coggins Insurance Agency, Inc.

If you would like a free General Liability Quote, please fill out the form below. If you have any questions, feel free to contact John Coggins at (850) 457-3299 or email him at jlcoggins@cogginsinsurance.com.
The field marked with (*) are required fields.
*	Full Name
*	Phone Number
*	Email Address:
*	Name and Address of Business
*	Type of Business
*	Specific Duties In Job
*	How many years of experience?
*	How many employees?	1 2 3 4 5-9 10-15 16-20 21 or more
	How many officers are in your business?	1 2 3 4 5 or more
*	How much is your payroll?
*	What is the total of your Annual Receipts?
*	Do you have any losses in the last 3 years?
	If there have been losses in the past 3 years, please list the amount and details?
*	Who is your current insurance carrier?
	What is the expiration date of your current insurance?
*	Have you had prior cancellations?	Yes No
	If prior cancellations, please list reason:
*	What coverage amounts would you like for premises and operations?	General Aggragate $100,000.00 General Aggragate $300,000.00 General Aggragate $500,000.00 General Aggragate $1,000,000.00 General Aggragate $2,000,000.00
*	How much would you like for each occurance?	$100,000.00 $300,000.00 $500,000.00 $1,000,000.00 $2,000,000.00
*	How much coverage would you like for Damage to Rented Premises?	$100,000.00 $300,000.00 $500,000.00 $1,000,000.00 $2,000,000.00
*	Would you like coverage on Medical Payments at $10,000.00?	Yes No
	Who may we thank for referring you to our Agency?